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What Doctors Think

Oct 13, 2011• 18

By David M Sack, MD

A number of years ago, Dr. Jerome Groopman published a wonderful book for the benefit of patients and their physicians, entitled How Doctors Think. It is an excellent description, illustrated by anecdotes, of the cognitive processes by which doctors arrive at diagnoses, and the pitfalls that are inherent in such calculations owing to the inherent strengths and weaknesses of human thought processes. For example, our tendency to consider conditions that we have seen recently, or those for which can easily imagine examples, is one habit discussed in some depth. It is a fascinating read (or in my case, listen, as I heard it on a CD in my car over the course of a couple of weeks.)

So Dr. Groopman has exposed well how doctors think. But how often do we reveal just what we are thinking? No more often, in my opinion, than we reveal our inner thoughts to friends and relatives in our personal lives – and in fact, considerably less often if we value our professional success. We occasionally let slip our attitudes in a moment of carelessness, a gesture, or the infrequent loss of temper. But for the most part, we try to embody the ideal of “equanimitas” that was advocated by one of our icons of modern medicine, the great doctor William Osler. There have been many learned treatises on this quality as to its benefits to a physician and his patients, and I have little of great insight to add on that topic.

But wouldn’t it be nice to occasionally allow ourselves to express what we really think? I always enjoy arriving home – usually somewhat later than I promised – to relate some of the triumphs and tragedies of the battles of the day. And this, of course, is when I get to say what I really think. It has occurred to me that I might even collect enough material to publish my own book, What Doctors Think.

My wife suggested an alternative or a sequel entitled Do Doctors Think?

I am choosing to ignore the suggestion for the purposes of this post.

Putting the IT in Care TransITions–Webcast

Oct 13, 2011

Heath 2.0’s JL Neptune will be on a panel in Washington DC tomorrow (Friday 14 October) to discuss the role of IT in Health Transitions–which is of course the topic of a major challenge with $40,000 in prize money in the i2 ONC Challenge program which Health 2.0 is running. The panel is part of a major meeting put on by several foundations and HHS. Details about the meeting are below–Matthew Holt:

The John A. Hartford Foundation, the Gordon and Betty Moore Foundation and Kaiser Permanente are convening key stakeholders in the innovation, healthcare provider, and IT vendor communities for an event Friday, October 14, 2011. Media partners for the event are Health Affairs and Health 2.0. The Office of the National Coordinator for Health IT (ONC) at the Department of Health and Human Services (HHS) and the HHS Partnership for Patients Initiative are also key participants. The agenda for this event is here. You can register for the webcast here. The webcast will pause during the breakout sessions from 8:45 am – 10:45 am ET.

These sessions will be in four topic areas:

1. Discharge process

2. Medication reconciliation

3. Information flow and feedback

4. Patient and care-giver activation

There’ll be facilitated discussion on Google Plus and Twitter during that portion of the meeting to discuss these topics. The three questions being posed are:

1. What are the most important problem statements from the patient’s and caregiver’s perspective that require our attention?

2. Where is IT effectively addressing these challenges now?

3. Where is innovation most needed now?

The webcast will then resume at 10:45 am until 12:00 noon ET when there will be a half hour break for lunch. The final portion of the event will then go from 12:30 pm until 3:00 pm ET, with a short break at 1:45 pm ET.

Healthbox: Deadline Next Week

Oct 13, 2011

By Dan Phillips

In the past year three health technology specific incubators have popped up. Rockhealth in San Francisco has been the most “in your face” promoting a message of outsiders coming into health care with mostly consumer-focused start-ups But the Mid-West and East Coast aren’t being left out. Recruiting later this year, Blueprint in New York has a tad more of a provider focus. But right now it’s the turn of HealthBox, the incubator from Sandbox Industries which runs the Blues venture fund. And with both their plan connections and their slightly higher level of investment, they should tempt a good group to move to Chicago for that cold winter!--Matthew Holt

Startup incubator Healthbox has entered its final week of applications, with the three-month program set to kick off in January with a class of ten teams. Submissions have already come in from 20 states and 4 countries, and include companies focused on provider workflow, consumer health, informatics, pharmacy and a number of other concentrations. Applications close October 16th and selected participants will be announced in December.

Healthbox provides a boost to healthcare technology startups through an intensive three-month program that offers participants $50,000 in seed capital, relevant topical forums, and access to a broad group of mentors, including successful industry leaders, investors, and entrepreneurs. Founded by Chicago-based VC and incubation firm Sandbox Industries, Healthbox is supported by some big players in healthcare, including BlueCross BlueShield, Walgreen Co., the California HealthCare Foundation and Merrick Ventures, to name a few. The program will culminate with an Investor Day in April 2012, during which each company will pitch to a large group of potential investors.

Thank U.S. Health Care for the Life of Steve Jobs

Oct 13, 2011• 53

By JOHN GOODMAN

On the very day that Steve Jobs died a new report suggests that the U.S. health care system is spending too much money on people near the end of their lives. The timing of the two events could not have been more ironic.

Had Jobs been under the care of the British National Health Service (NHS) or the Canadian Medicare system, he almost certainly would have died two years earlier. That would have been a major loss for the world, by anyone’s reckoning.

Here’s the back story. In 2004 Steve Jobs was diagnosed with pancreatic cancer. He reportedly underwent successful surgery. Then, in 2009 he received a liver transplant. He died on Wednesday.

I haven’t seen Jobs’ medical records and I have made no real attempt to get the details about his medical condition. But for the point I want to make here, none of that really matters. Jobs’ case is interesting because of the issues it raises.

In most places in the world today a diagnosis of pancreatic cancer would be considered a death sentence. Aggressive treatment of the condition would be considered a poor use of medical resources — one involving considerable expense in return for only a few extra months of life. Perhaps Jobs’ cancer was of a rare variety that could be removed by surgery.

The Acute Model

Oct 12, 2011• 2

By BOB WACHTER, MD

Besides studying patient safety and watching all five seasons of The Wire, my other major goal for my London sabbatical was to understand the way the Brits organize hospital care. Mirroring the U.S. hospitalist movement, a new field—called “acute medicine”— emerged about 15 years ago and became the country’s fastest growing specialty.

But there is a key difference: acute physicians are hospitalists working inside a smaller box, the acute medical unit. While the young field has enjoyed some striking successes, I recently spoke at its national conference and challenged acute physicians to be a bit more ambitious—to put a little more of the “disruptive” in their disruptive innovation.

To understand the different evolutionary paths of the U.S. and UK’s systems of hospital care, it’s important to understand the primordial seas from which hospitalists and acute physicians emerged. Whereas the U.S. hospitalist model has all-but-replaced a system in which the primary care physician was expected to be the physician-of-record in the hospital, the UK never had such a system. Instead, general practitioners in Britain have always confined their work to the outpatient world; patients in need of hospital care have been handed off to different physicians since the days of Alexander Fleming. But the traditional model has been for those physicians to be subspecialists, with patients admitted to wards run by consultants: the GI ward, the endocrine ward, the geriatrics ward, and so on.

There are clearly certain diseases—acute MI and stroke come to mind—in which such narrow, specialty-focused wards deliver better outcomes of care. But for the vast majority of hospitalized patients, who are rarely cooperative enough to have just one thing wrong with them, the requirement to pigeonhole patients into a specialty unit is problematic. A 2002 American study found that when patients happened to be cared for by the “wrong” specialist (the cardiology service, say, taking care of an asthma patient), both lengths of stay and mortality rates spiked.

Orphan Innovations

Oct 11, 2011• 2

By TIMOTHY WILSON

If someone has invented a successful, innovative, cost-effective social program, doesn’t it seem likely that it would spread quickly to other communities? Susan Evans and Peter Clarke have written a fascinating article detailing why many programs become “orphan innovations” that no one else adopts.

The authors describe a program started by a retired produce wholesaler in Los Angeles, who convinced distributors to donate slightly spoiled produce to food banks. Before long, poor families were receiving fresh fruits and vegetables that would have been dumped in landfills. Evans and Clarke took it upon themselves to make sure that this program was adopted in other cities, but ran into many roadblocks, such as skepticism from overworked local officials that the program would work. Eventually, through sheer determination, they succeeded: the program spread to dozens of communities. But it took 20 years of hard work, creativity, cajoling, and financial support.

Their conclusion? A social program cannot simply be transferred from one locale to another. Instead, it has to be customized at each new location. Unlike a fast food chain, that plops a carbon copy of a restaurant down in every community in American, social programs have to be adapted to the particular staff, clients, and ecology of each setting.

There are valuable lessons to be learned here for those of us interested in social psychological interventions that improve human welfare. There is a growing movement to translate social psychological theory into interventions that help people in the real world, including ones that help people recover from traumatic events, prevent child abuse, reduce adolescent behavior problems, and close the achievement gap in education (as I chronicle in my book Redirect). Critically, these interventions are being tested with well-controlled experiments, to see if they work. This is a huge advance over relying on common sense, which has led to the wide-spread adoption of programs that don’t work or do harm (see my earlier post, Testing, Testing).

Paul Ryan Is Right (And Wrong)

Oct 11, 2011• 5

By Roger Collier

Having cost the Republican Party a Congressional seat earlier this year with his plan to turn Medicare into a voucher program, House Budget Committee Chair Paul Ryan is back with an even more sweeping health care proposal.

Ryan’s latest offering, unveiled in a speech a week ago at Stanford University’s conservative Hoover Institution, is nothing less than a blueprint for replacing the Affordable Care Act with a consumer-driven model that would eliminate the current tax-exempt treatment of employer-paid health insurance.

Is Ryan right? Or wrong?

Ryan believes that exempting health care benefits from employee income tax leads to insurance choices that are unnecessarily costly (since they are effectively subsidized), insufficiently tailored to employee needs (since few choices are offered), inadequately valued (since the employee isn’t paying), and unreasonably tie employees to their jobs (since they may not be able to move without switching insurance). He also believes the present system is unfair: higher-paid employees get a greater tax advantage, while employees of smaller businesses have fewer (or no) options at higher prices than their peers in larger corporations.

He’s right! Common sense says that people are likely to choose the most generous coverage available if it is free or offered at a very low price, while employers—especially those who must negotiate union contracts—see tax-subsidized health insurance as a “better buy” than salary payments.

Reforming the NPDB: An Open Letter

Oct 10, 2011• 1

Kathleen Sebelius, Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Mary K. Wakefield, Administrator
Health Resources and Services Administration
5600 Fishers Lane
Rockville, MD 20857

Re: Public Use File of the National Practitioner Data Bank

Dear Secretary Sebelius and Administrator Wakefield:

The undersigned are academic researchers who work in the areas of public health, health care quality/patient safety, medical liability, and related fields. (Signatories are listed alphabetically by last name. Academic affiliations are provided for purposes of identification only.)

We write to condemn, in the strongest possible terms, HRSA’s recent decision to make the Public Use File (PUF) of the National Practitioner Data Bank (NPDB) unavailable. We also request that HRSA restore the PUF’s availability immediately.

The NPDB is the only nationwide database of closed medical malpractice claims that is publicly available to researchers. Academics use it extensively. A search on “National Practitioner Data Bank” in Google Scholar’s “articles and patents” database returned a multitude of hits. The same search run in WESTLAW’s “journals and law reviews” database returned 576 articles. In PubMed, the search generated 399 articles. Not all of these articles contain new empirical findings, but many do, and the sheer number of publications attests to the NPDB’s importance. The NPDB is an indispensable resource for academic researchers.

Why Drug Company-Doctor Interactions Are Good For Patients

Oct 10, 2011• 3

By Diane Bieri

Transparency is a powerful tool. Framed properly to illustrate the collaboration between America’s biopharmaceutical companies and physicians, it can empower patients to become more engaged in the care they receive. Transparency can also lead to misinterpretations, discouraging even the most ethical, unbiased doctors from future collaborations that could improve patient health.

ProPublica, whose reporters, Tracy Weber and Charles Ornstein, penned The Times’ Sept. 8 Op-Ed article, “What the doctor ordered,” recently updated its “Dollars for Docs” database of doctors who have received money from biopharmaceutical companies. By listing only names and compensation figures with limited context, patients may assume their care is compromised by tainted doctors. Such an incomplete picture creates unnecessary confusion and, in most cases, is completely unfounded.

We agree with ProPublica that patients should know that many physicians work with biopharmaceutical companies. To be completely transparent, however, they should also know why it benefits them and how the relationship is closely managed to ensure it remains ethical.Continue reading…